Pre-Op Health Questionnaire

"*" indicates required fields

Step 1 of 4 - Please complete the Patient and Operation Details below:

Please note: This form can be completed from ANY device

If you would rather complete this on a bigger screen, please click 'Save Your Form To Complete Later' below or visit drorisonkim.com.au from your desktop or laptop

The hospital will commonly have you complete a similar questionnaire prior to your admission for their own records - this is usually not provided to Dr Kim. To ensure Dr Kim is properly prepared for your anaesthetic, please complete this questionnaire to the best of your ability.

On average, it takes 5-10 minutes to complete this questionnaire. If you are unable to complete it in one session (or under 15 minutes), you can save your answers and return at any time by clicking the “Save Your Form to Complete Later” button at the bottom of the questionnaire.

To enable you to complete your questionnaire as quickly as possible, please have on hand:
- Your health care cards (Medicare card, private fund card etc)
- Contact details of your usual Doctors (GP & Specialists)
- Details of your current medications
- A scanned PDF or JPG of any results or letters you wish to send your Anaesthetist

Tip: If you wish to navigate back to a previous page at any stage, please only use the blue “PREVIOUS” button at the bottom of the page.

* Denotes a required field

Patient Details:

Patient's Name*

First Last

Is this you?*

Yes

Your Name

Relationship to Patient

Please complete all of the following questions based on the patient
ie. when the question refers to "you" please describe the patient's health.

Gender*

Male

Female

Phone Number(s)*

Patient's Age*

(in years - if a child, please use a decimal if desired, eg. 2years 6months = 2.5)

Operation Details:

Surgeon*

Hospital

Operation*

(the procedure being performed)

Date of Operation

DD slash MM slash YYYY

Why are you having this operation?

(what symptoms or diagnosis made you to decide to undergo this procedure?)

Patient Details:

Height (cm)

Weight (kg)*

Have you or any blood relatives ever had any problems with anaesthetics in the past?*

Yes

If yes, please provide details

Details of previous anaesthetics

(if you can remember when and in what hospitals you previously underwent an anaesthetic, providing these details can help in retrieving previous anaesthetic records meaning past problems could potentially be avoided)

Do you have any allergies?*

(especially to medications including antibiotics, latex products, foods or iodine)

Yes

If yes, what are you allergic to and what is the reaction?

Do you take regular medications?*

(this includes all tablets, puffers, patches, sprays, injections, eye drops etc.)

Yes

If yes, please detail each medication with the amount taken and how often you take it

(please list each medication on a new line)

Do you have, or have you ever had, any of the following?

Any trouble with your heart or cardiovascular system?*

(this could include high blood pressure, chest pains, angina, heart attacks, coronary artery stents, coronary artery bypass surgery, heart rhythm problems, having a pacemaker or defibrillator, strokes or mini strokes)

Yes

If yes, please provide details (make sure you include your Cardiologist's name and contact details if applicable)

Shortness of breath climbing less than 2 flights of stairs or whilst walking for 30 minutes on flat ground?*

Yes

Any trouble with your lungs or respiratory system?*

(this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, or smoking-related problems)

Yes

If yes, please provide details (make sure you include your Respiratory or Sleep Doctor's name and contact details if applicable)

Diabetes?*

Yes

How old when diagnosed?

How is your diabetes treated?

(select all that apply)

Insulin

Tablets

Diet

If you use insulin, at what blood glucose level (BGL) would you start to get symptoms of a 'hypo'?

(only if this is known, ie. your anaesthetist needs to maintain your BGL above this value whilst you undergo your procedure)

Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia?*

Yes

If yes, please select the following which apply

(multiple options can be selected)

When bending forward or lying flat you get a burning sensation or acid rising into your mouth or throat, or you get this same sensation waking you from sleep

You previously suffered from this burning sensation or acid rising into your mouth or throat, but since commencing treatment this no longer occurs

You don't get this acid rising sensation, but you do suffer from stomach/abdominal discomfort or burning

You previously suffered from this stomach/abdominal discomfort or burning, but since commencing treatment this no longer occurs

Thyroid disease?*

Yes

If yes, please select the following which apply

Your thyroid hormone levels are normal

Your last blood test was within 12 months

Your breathing becomes difficult when lying flat

You are unsure on your current thyroid disease status

Do you have an enlarged thyroid gland, otherwise called a goitre?

Yes

Your Endocrinologist's name and contact details

Kidney condition?*

Yes

If yes, please provide details (make sure you include your Nephrologist, Kidney or Dialysis Doctor's name and contact details if applicable)

Blood clots or excessive bleeding?*

(eg. deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia, and others)

Yes

If yes, please provide details (make sure you include your Haematologist or Blood Doctor's name and contact details if applicable)

Is there a chance you could be pregnant?

Yes

With regards to your teeth or dentition - what do you have?*

(please select all that apply)

Loose tooth or teeth

Chipped tooth or teeth

Caps, crowns, or veneers

Implant(s)

Bridge(s)

Partial upper dentures

Partial lower dentures

Full upper dentures

Full lower dentures

Your own teeth +/- fillings only

Please indicate the pain relievers or analgesics that have worked well for you previously*

Paracetamol, eg. Panadol

Anti-inflammatories, eg. Nurofen, Voltaren, Celebrex, Mobic

Tramadol, eg. Tramal

Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop

Strong opioids, eg. OxyNorm, Endone, Targin, Sevredol

None of the above

Other

Please indicate the pain relievers or analgesics that you must avoid or should not use*

Paracetamol, eg. Panadol

Anti-inflammatories, eg. Nurofen, Voltaren, Celebrex, Mobic

Tramadol, eg. Tramal

Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop

Strong opioids, eg. OxyNorm, Endone, Targin, Sevredol

Other

I am not aware of any pain relievers or analgesics that I must avoid or should not use

Which "Other" pain relievers or analgesics should you avoid?*

(please include as much detail as possible)

Any other health issues you wish to mention?*

Yes

If yes, please provide details

Upload medical information

(please feel free to upload any medical reports, test results, Specialist letters or supporting information)

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, Max. file size: 128 MB.

Other Details:

Do you have someone to collect you from hospital and who can help you for the first 24 hours after discharge?*

Yes

Name and telephone numbers of your doctors

(GPs and Specialists)

Do you give your consent for me to contact your other doctors if required?*

(to provide you with the safest anaesthetic Dr Kim may need to contact your other doctors to obtain test results, specialist letters, or other information. This allows better understanding of your health, meaning your anaesthetic can be individualised appropriately)

Yes

Are you entitled to access Medicare rebates by the Australian Government?*

(ie. do you have a green Medicare card?)

Yes

Do you have private health insurance?*

Yes

If yes, to which health fund do you belong and what is your member number?

Are you currently covered for in-hospital treatment?

Yes

Unsure

Would you like an estimate of the Anaesthetic Fee pre-operatively?*

Yes

No - I am happy to proceed as is

If yes, how would you like to receive the quote or estimate of the Anaesthetic Fee?

(please select all that apply)

SMS/text message

Phone call

Preferred method to pay Anaesthetic Fee?*

Credit Card

Cash

Direct Deposit (eg. via an internet funds transfer)

Workers Compensation or Defence Force account

Other

Please advise details of payment here

Dr Kim will be sent the information submitted via this questionnaire. Depending upon your answers, Dr Kim may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, Dr Kim may be satisfied with the information submitted and be ready to proceed with your anaesthetic as is.

Would you like to receive a phone call from your anaesthetist prior to your procedure?*

Yes

Only if my anaesthetist has specific issues they wish to discuss

I'm not fussed

By submitting this pre-op health questionnaire on anaestheticgroup.com.au you confirm this information can be sent to your anaesthetist in accordance with our privacy policy, the information you have provided is true and correct to the best of your knowledge and this information can be relied upon by your anaesthetist in making clinical decisions.

Is there anything else you would like to mention?*

Yes

If yes, please provide details

This field is for validation purposes and should be left unchanged.

Pre-Op Health Questionnaire – Dr Kim

Patient Details:

Operation Details:

Patient Details:

Do you have, or have you ever had, any of the following?

Other Details:

PATIENTS

SURGEONS

ANAESTHETISTS